MS NO: ONG-18-45
Obstetrics: Original Research
Recommendations From Cannabis
Dispensaries About First-Trimester
Cannabis Use
Betsy Dickson, MD, Chanel Mansfield, MPH, Maryam Guiahi, MD, MSc, Amanda A. Allshouse, MS,
Laura M. Borgelt, PharmD, Jeanelle Sheeder, PhD, Robert M. Silver, MD, and Torri D. Metz, MD, MS
OBJECTIVE: To characterize recommendations given to
pregnant women by Colorado cannabis dispensaries
regarding use of cannabis products for nausea during
the first trimester of pregnancy.
METHODS: This was a statewide cross-sectional study in
which advice about cannabis product use was requested
using a mystery caller approach. The caller stated she was 8
weeks pregnant and experiencing morning sickness. Dis-
pensaries were randomly selected from the Colorado
Department of Revenue Enforcement Division website.
The primary outcome was the proportion of marijuana
dispensaries that recommended a cannabis product for use
during pregnancy. We hypothesized that 50% of dispensaries
would recommend use. A sample size of 400 was targeted to
yield a two-sided 95% CI width of 10%. Secondary out-
From the University of Colorado School of Medicine and the Colorado School of
Public Health, Aurora, Colorado; the University of Utah Health, Salt Lake City,
Utah; and Denver Health and Hospital Authority, Denver, Colorado.
Dr. Metz is supported by the Eunice Kennedy Shriver National Institute of
Child Health and Human Development under award number
5K12HD001271-18. This project was also supported by the Colorado Clinical
and Translational Sciences Institute with the Development and Informatics Ser-
vice Center under award number UL1 RR025780. The content is solely the
responsibility of the authors and does not necessarily represent the official views
of the National Institutes of Health.
Presented as a poster at the Society for Maternal-Fetal Medicine’s 38th Annual
Pregnancy Meeting, January 29–February 3, 2018, Dallas, Texas.
Each author has indicated that he or she has met the journal’s requirements for
authorship.
Corresponding author: Torri D. Metz, MD, MS, 777 Bannock Street, MC 0660,
Denver, CO 80204; email: torri.metz@dhha.org.
Financial Disclosure
Dr. Borgelt received grant funding from the Colorado Department of Public
Health and Environment (CDPHE) for a study evaluating the use of cannabidiol
for the treatment of refractory pediatric epilepsy. Additionally, she has served on
seven different working groups for the Colorado Department of Revenue and
CDPHE regarding use of cannabis and patient safety. The other authors did not
report any potential conflicts of interest.
© 2018 by American College of Obstetricians and Gynecologists. Published by
Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/18
VOL. 131, NO. 6, JUNE 2018
comes included the proportion endorsing cannabis use as
safe during pregnancy, specific product recommendations,
and encouraging discussion with a health care provider.
Recommendations were compared by licensure type (med-
ical, retail, or both) and location (rural vs urban).
RESULTS: Of the 400 dispensaries contacted, 37% were
licensed for medical sale (n5148), 28% for retail (n5111),
and 35% for both (n5141). The majority, 69% (277/400),
recommended treatment of morning sickness with can-
nabis products (95% CI 64–74%). Frequency of recom-
mendations differed by license type (medical 83.1%,
retail 60.4%, both 61.7%, P,.001). Recommendations
for use were similar for dispensary location (urban 71%
vs nonurban 63%, P5.18). The majority (65%) based their
recommendation for use in pregnancy on personal opin-
ion and 36% stated cannabis use is safe in pregnancy.
Ultimately, 81.5% of dispensaries recommended discus-
sion with a health care provider; however, only 31.8%
made this recommendation without prompting.
CONCLUSION: Nearly 70% of Colorado cannabis dis-
pensaries contacted recommended cannabis products to
treat nausea in the first trimester. Few dispensaries
encouraged discussion with a health care provider
without prompting. As cannabis legalization expands,
policy and education efforts should involve dispensaries.
(Obstet Gynecol 2018;131:1031–8)
DOI: 10.1097/AOG.0000000000002619
M arijuana use in pregnancy may have adverse
effects on the fetus, including fetal growth
restriction and long-term neurologic consequences.1,2
The American College of Obstetricians and Gynecol-
ogists states, “obstetrician–gynecologists should be
discouraged from prescribing or suggesting the use of
marijuana for medicinal purposes during pre-
conception, pregnancy, and lactation.”2
Expanding legalization may increase use among
pregnant women and may be accompanied by
OBSTETRICS & GYNECOLOGY 1031
increased perception of safety without data to assure
safety.3 A cross-sectional study of women who are
clients of the Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC) in the state
of Colorado found that 48% of women who reported
current marijuana use also reported marijuana use
during their prior pregnancy “to help with nausea or
vomiting.”4
Pregnant women who are interested in using
marijuana may refrain from seeking safety informa-
tion from health care providers as a result of fear of
legal repercussions and instead seek advice from
cannabis retailers. The primary objective of this study
was to estimate the proportion of cannabis dispensa-
ries that recommended cannabis products to a caller
posing as pregnant and experiencing nausea in the
first trimester of pregnancy. Secondary objectives
were to characterize recommendations given to preg-
nant women by Colorado cannabis dispensaries
regarding use of cannabis products. It was hypothe-
sized that 50% of dispensaries would recommend
a cannabis product and that recommendations would
differ by dispensary type (medical, retail, or both) and
geographic location (urban vs rural).
MATERIALS AND METHODS
This cross-sectional study of cannabis dispensaries in
Colorado used a mystery caller approach. The study
was approved by the Colorado Multiple Institutional
Review Board (number 17-0637). Minor deception
(eg, posing as a pregnant caller) was deemed neces-
sary to obtain an accurate assessment of how cannabis
dispensaries advise pregnant women. Recommenda-
tions, advice, and comments included in this study are
limited to the individual dispensary employee who
responded to the questions and may or may not
reflect the policies or recommendations of the actual
dispensary. However, the term “dispensary” is used to
reflect the individual employee who answered the
phone. All registered dispensaries in Colorado will
be informed of the results when published.
The target population consisted of all cannabis
dispensaries in Colorado. The sampling frame was
a list of licensed dispensaries on the Colorado
Department of Revenue’s Enforcement Division web-
site (accessed December 1, 2016).5 There were 982
licenses among 724 individual dispensaries with three
mutually exclusive license types: 270 (37%) medical
only, 258 (36%) both (medical and retail), and 196
(27%) retail only. In Colorado, medical dispensaries
are licensed pursuant to the medical code to operate
a business and sell medical marijuana to registered
patients and to primary caregivers.6 Retail
1032 Dickson et al Cannabis Dispensary Recommendations
dispensaries are entities licensed to purchase retail
marijuana and retail marijuana concentrate from
a retail marijuana cultivation facility or manufacturing
facility and to transfer these products to consumers.7
A dispensary can operate as both a medical and retail
dispensary if they obtain both licenses and also con-
firm that there will be no sales of medical marijuana to
individuals younger than age 21 years at the
combined-use location.7
Sampling occurred proportionally by dispensary
type. Because some municipalities allow only certain
license types, sampling was further stratified by
municipality within license type. For medical dispen-
saries, municipal regions were Colorado Springs
(50%), Denver (23%), and elsewhere (27%); for both
medical and retail license types, regions were munic-
ipal Denver (58%) and elsewhere; and for retail-only
licenses, municipal regions were Denver and Aurora
(24%) and elsewhere (76%). Within each strata,
dispensaries were selected randomly without replace-
ment using SAS SURVEYSELECT with a frequency
to proportionately represent each strata in a full
sample. To replace unavailable dispensaries to
achieve the targeted sample size, alternative dispen-
saries were selected randomly without replacement
within the appropriate strata among previously unse-
lected dispensaries again using SAS
SURVEYSELECT.
The Colorado Department of Revenue Enforce-
ment Division website provided the following infor-
mation in a publically available Microsoft Excel
spreadsheet: license name, business name, license
number, address, city, and zip code. Phone numbers
were obtained through an online search of the
dispensary name and then crosschecked against the
corresponding address in the registry.
Two investigators (B.D. and C.M.) contacted
selected dispensaries using a phone script to inquire
about cannabis use for nausea in pregnancy (Box 1).
The phone script was developed by the investigators
and piloted with 15 dispensaries in Alaska, Oregon,
and Washington. Each caller stated they were 8 weeks
pregnant, feeling really nauseated, and asked, “Are
there any products that are recommended for morn-
ing sickness?” The remainder of the conversation uti-
lized the telephone script to obtain responses (Box 1).
If any cannabis products were recommended at
any point during the phone call, the response of the
dispensary was considered as affirmative for cannabis
recommendation. If the dispensary employee noted
that it was against policy to make a recommendation
or claimed to not be able to make a recommendation,
but then went on to recommend cannabis, this was
OBSTETRICS & GYNECOLOGY

Box 1. Phone Script
“Hi, I’m 8 weeks pregnant and feeling really nauseated.
Are there any products that are recommended for
morning sickness?”
Prompts in response to no recommendation:
1. What if I have a medical card? (If asked why you
have a card, state it is for chronic pain from a car
accident.)
2. Why not?
Prompts in response to recommendation:
1. What product?
a. Why?
2. How often should I use it?
3. Is it safe to take during pregnancy?
a. If only maternal risks are addressed, ask: Is it
also safe for my baby?
b. If only fetal risks are addressed, ask: Is it also
safe for me?
Before closing call:
Should I talk to my doctor about this (if no recommendation
previously made to discuss with health care provider)?
also recorded as an affirmative response. If the
dispensary employee asked the caller to come into
the business in person for advice, the response was
recorded as “no recommendation made.”
If cannabis products were not initially recom-
mended, the caller asked whether a recommendation
could be made if she had a medical marijuana card.
The caller stated she had a medical marijuana card for
chronic pain after a car accident. In addition, dispen-
saries were asked whether the caller should discuss
cannabis use with a health care provider. Dispensaries
were documented as recommending this before being
prompted, after being prompted, or not recommend-
ing even after prompting. To qualify for a medical
marijuana card in the state of Colorado, an adult has
to be a Colorado resident 18 years or older, and have
a qualifying medical condition (cancer, glaucoma,
human immunodeficiency virus or acquired immu-
nodeficiency syndrome, cachexia, persistent muscle
spasms, seizures, severe nausea, severe pain, post-
traumatic stress disorder) as determined by a licensed
Colorado physician.
Recommendation for use was categorized as
personal opinion, referenced research, referenced
dispensary policy, deferred to health care provider,
or did not specify. Recommendations were classified
as personal opinion if the dispensary employee stated
“in my opinion” or used anecdotes.
For analysis, dispensaries were categorized as
urban and rural according to guidelines published
VOL. 131, NO. 6, JUNE 2018
by the Colorado Rural Health Center and utilized by
the Colorado Department of Public Health and
Environment.8 This resource classifies all zip codes
in Colorado as urban, rural, or frontier. Given the
small number of dispensaries in the frontier area, fron-
tier and rural dispensaries were grouped together as
rural for analysis.
All calls were digitally recorded, which is legally
permissible in Colorado. Answers to each branching
point were documented on a paper data sheet to avoid
interruptions and for future reference if the digital
audio recording was unavailable. The audio record-
ings and paper data sheets then were used to add
responses to Research Electronic Data Capture.9 To
avoid dispensary identification, study identification
numbers for each dispensary were used. The paper
data sheets were shredded and the audio recordings
deleted at the conclusion of data analysis.
Three attempts were made to contact each
dispensary within listed business hours. If all three
attempts were unsuccessful, the dispensary was re-
corded as “unavailable.” The dispensary was also con-
sidered “unavailable” if no phone number was
identified for the location or if the location never
opened or had yet to open. Unavailable dispensaries
were replaced with another randomly selected dispen-
sary within the same stratum as noted previously. The
caller did not request any identifying information
about the dispensary employee.
The primary outcome was the proportion of
cannabis dispensaries that recommended cannabis
use to a pregnant caller reporting nausea in the first
trimester. Secondary outcomes included mention of
maternal or fetal risks, stated benefits of cannabis use
during pregnancy, specific product recommendations
including dosing and frequency of use, warning of
possible legal consequences, further discussion with
a health care provider, length of the phone call,
rationale for the product recommended, and reported
source of information on which recommendations
were based.
It was hypothesized that 50% of dispensaries
would recommend cannabis use to a pregnant caller
(the primary outcome). A sample size of 400 was
targeted to yield a two-sided 95% CI with width of
10%. The proportions of the primary and secondary
endpoints were summarized as percentage and exact
95% CI overall, by three-category dispensary type,
and two-category population density (urban vs rural).
Method of delivery (ie, inhalation, topical, edible) was
compared across type of product recommended.
Differences in endpoints by dispensary type and
population density were tested using an exact Pearson
Dickson et al Cannabis Dispensary Recommendations 1033
x2 test. Skewed continuous variables (ie, call duration)
were summarized with geometric mean and 95% CIs.
Representative quotations from retailers about the
nature of the advice were selected to add context to
reported quantitative data.
RESULTS
Calls were completed in June and July 2017. Inves-
tigators contacted 465 dispensaries. Valid calls were
achieved in 76% of calls to retail dispensaries, 75% of
medical dispensaries, and 89% of both license type
dispensaries (P5.001). This resulted in 400 valid calls
and achieved the target sample size (n5400) of re-
sponses (Fig. 1). The average length of phone call
was 2.4 minutes (95% CI 2.3–2.6 minutes). Of the
400 dispensaries included, 37% were licensed as med-
ical (n5148), 35% were licensed as both medical and
retail (n5141), and 28% as retail only (n5111). Addi-
tionally, 80.0% were urban and 20.0% were rural.
The majority, 69% (277/400), recommended
cannabis products for “morning sickness” (95% CI
64–74%). Frequency of recommendation differed by
license type (medical 83.1%, retail 60.4%, both 61.7%,
P,.001) with medical dispensaries recommending
most frequently. Recommendations for use were sim-
ilar by population density (urban 71% vs rural 63%,
P5.18). Of the 277 dispensaries that recommended
a product, 65% based their recommendation for use
in pregnancy on personal opinion, 30% did not spec-
Fig. 1. Study population flow diagram.
Dickson. Cannabis Dispensary Recommendations. Obstet Gynecol 2018.
1034 Dickson et al Cannabis Dispensary Recommendations
ify a reason, and 36% stated cannabis use is safe in
pregnancy (Table 1). Recommendations based on per-
sonal opinion differed by dispensary type with medi-
cal dispensaries most frequently basing their
recommendation on personal opinion (medical 85%,
retail 57%, both 45%, P,.001). Some dispensary em-
ployees (9% [36/400]) initially stated they could not
recommend any products, but then proceeded to give
a recommendation, which occurred similarly by dis-
pensary type (8.8% medical, 7.2% retail, 10.6% both,
P5.65). Recommendations for use and basis for rec-
ommendations did not differ based on population
density (Table 2).
Overall, 35.7% (n599) endorsed safety of canna-
bis products during pregnancy. The proportion of dis-
pensaries that endorsed safety did not differ by
dispensary type (medical 40.7%, retail 28.4%, and
both 34.5%, P5.24). Only 4.7% reported a risk of fetal
harm and 1.8% reported a risk of both maternal and
fetal harm. The proportion endorsing risk did not dif-
fer by dispensary type (Table 1) or by population
density (Table 2). One dispensary employee stated,
“After 8 weeks everything should be good with con-
suming like alcohol and weed and stuff, but I would
wait an extra week.”
Of the 277 dispensaries that recommended canna-
bis use, 99% (n5275) recommended a specific cannabis
type. All products were recommended at similar rates
by dispensary type; 26% recommended use of
OBSTETRICS & GYNECOLOGY
Table 1. Cannabis Use Guidance Among Medical, Retail, and Both Dispensaries That Recommended
Products for Nausea in Pregnancy

Response From Dispensary to Medical Retail Medical and Retail

“Pregnant” Caller Overall License License License P*

Primary outcome n5400 n5148 n5111 n5141

Recommended cannabis† 69 (64–74) 83 (76–89) 60 (51–70) 62 (53–70) ,.001
Secondary outcomes n5277 n5123 n567 n587
Report of recommendation for use based
on
Personal opinion 65 (59–71) 85 (77–90) 57 (44–69) 45 (34–56) ,.001
Referenced research 6 (3–9) 7 (3–14) 3 (0–10) 6 (2–13) .46
Referenced dispensary policy 1 (0–3) 1 (0–5) 0 (0–5) 1 (0–6) ..99
Deferred to health care provider 3 (1–6) 2 (0–6) 0 (0–5) 7 (3–15) .014
Did not specify 30 (24–35) 9 (5–16) 40 (28–53) 50 (39–61) ,.001
Reported safety of cannabis use
Stated cannabis use safe 36 (30–42) 41 (32–50) 28 (18–41) 34 (25–45) .24
Potential for fetal harm 5 (3–8) 4 (1–9) 1 (0–8) 8 (3–16) .15
Potential for both fetal and maternal 2 (1–4) 2 (0–6) 4 (1–13) 0 (0–4) .11
harm
Unsure or depends on certain criteria 53 (47–59) 53 (44–62) 55 (43–67) 53 (42–64) .95
Deferred to health care provider 15 (11–20) 15 (9–22) 15 (7–26) 15 (8–24) ..99
Data are % (exact 95% CI). Responses are not mutually exclusive.
* P values for 332 comparisons using a Pearson exact x2.
†
Provides denominator for percentages in remainder of rows.

cannabidiol-only products, 17% tetrahydrocannabinol- Although the majority of dispensaries encouraged

only products, and the remaining (56%) recommended
products with both cannabidiol and tetrahydrocannabi-
nol (P5.40).
Not all dispensaries recommended a specific
method of delivery (ie, inhalation, edible) and some
recommended more than one method. Of the 277 that
recommended marijuana, 90% (248/277) recommen-
ded a method of use; the most frequently recommen-
ded methods were edibles (50.5%), inhalation (37.9%),
and tinctures (32.1%) followed by topical, including
salve, spray, and lotion (18.1%), pills (16.6%), drinks
(11.6%), and concentrate (5.8%).
Among all dispensaries, in response to whether
the caller should discuss cannabis use with a health
care provider, 13.5% of dispensaries stated they were
unsure or equivocal; this differed by dispensary type
(medical 16.9%, retail 16.2%, and both 7.8%, P5.046).
Overall, 81.5% of dispensaries recommended discus-
sion of cannabis use with a health care provider (med-
ical 79.7%, retail 80.2%, and both 84.4%, P5.55).
However, only 31.8% of all dispensaries made the
recommendation to talk to a health care provider
(medical 33.8%, retail 24.3%, and both 35.5%,
P5.02) without prompting with retail-only dispensa-
ries being least likely to make this recommendation.
One dispensary employee stated, “Highly, highly rec-
ommend talking to your doctor. Always tell your doc-
tor everything you’re putting in your body.”
discussion with a health care provider, approximately
one fourth (24.6%) of dispensaries recommended the
caller obtain more information by doing online
research, and this was not significantly different by
dispensary type (medical 23.3%, retail 32.4%, and
both 19.9%, P5.06). Rural dispensaries were more
likely to recommend use of the internet to research
cannabis use in pregnancy (urban 22.9% vs rural
31.7%, P5.11). No other comparisons by urban vs
rural yielded significant differences (data not shown).
Callers were warned of possible drug testing during
pregnancy (14.1%); this differed by license type (med-
ical 22.1%, retail 7.2%, and both 11.4%, P5.002) with
medical dispensaries most frequently endorsing this
warning.
Of the 123 dispensaries that did not initially
recommend using a cannabis product, only one
dispensary (0.8%) proceeded to give a recommenda-
tion when the caller disclosed she had a medical
marijuana card (P..99). In all other cases, there was
still no recommendation made when the caller dis-
closed she had a medical marijuana card.
Box 2 includes additional representative quotes
from dispensary employees in response to the open-
ended standardized phone script questions. The
response may not necessarily be directly associated
with the specific question as a result of the open-
ended nature of the questions.

VOL. 131, NO. 6, JUNE 2018 Dickson et al Cannabis Dispensary Recommendations 1035
Table 2. Cannabis Use Guidance Among Urban and Rural Dispensaries That Recommended Products for
Nausea in Pregnancy

Response From Dispensary to “Pregnant” Caller Urban Rural P*

Primary outcome n5320 n580

Recommended cannabis† 71 (66–76) 63 (51–73) .18
Secondary outcomes n5227 n550
Report of recommendation for use based on
Personal opinion 67 (61–73) 56 (41–70) .14
Referenced research 5 (2–9) 10 (3–22) .18
Referenced dispensary policy 1 (0–3) 0 (0–7) ..99
Deferred to health care provider 3 (1–6) 4 (0–14) .64
Did not specify 28 (22–35) 36 (23–51) .31
Reported safety of cannabis use
Stated cannabis use safe 35 (29–42) 38 (25–53) .75
Potential for fetal harm 5 (2–9) 4 (0–14) ..99
Potential for both fetal and maternal harm 1 (0–4) 4 (0–14) .22
Unsure or depends on certain criteria 54 (47–60) 52 (37–66) .88
Deferred to health care provider 16 (12–22) 8 (2–19) .19
Data are % (exact 95% CI). Responses are not mutually exclusive.
* P values for 232 comparisons using a Pearson exact x2.
†
Provides denominator for percentages in remainder of rows.

DISCUSSION advice that cannabis dispensaries can provide to cus-

The majority of cannabis dispensaries in Colorado
recommended cannabis products for morning sick-
ness and their recommendation for use was based
predominantly on personal opinion. Medical dispen-
saries were more likely than retail or both license type
dispensaries to recommend cannabis products. The
type of cannabis product most frequently endorsed
was combined tetrahydrocannabinol and cannabidiol
and the most frequently recommended method of use
was edibles. Although 80% of dispensary respondents
ultimately recommended discussion with a health care
provider, the majority needed prompting before
making this recommendation.
Given the concern for potential adverse effects on
the fetus with maternal cannabis use, the American
College of Obstetricians and Gynecologists recom-
mends against the use of cannabis products in women
who are pregnant.1,2 Public health efforts in Colorado,
the first state to legalize marijuana for recreational use,
have similarly focused on discouraging cannabis use
during pregnancy and lactation.10 According to the
Code of Colorado Regulations, all cannabis products
in the state of Colorado are required to have the fol-
lowing statement on every container: “There may be
additional health risks associated with the consump-
tion of this product for women who are pregnant,
breastfeeding, or planning on becoming pregnant.”6,7
Despite this warning, Colorado and other states that
have legalized marijuana have refrained from prohib-
iting marijuana use during pregnancy.11–13 There are
currently no regulations about recommendations or
tomers in Colorado.6,7
Our findings are consistent with other studies in that
the majority of advice given by cannabis dispensary
employees appears to be based on personal opinion. A
study by Haug et al14 found that only 20% of cannabis
dispensary employees received formal medical or scien-
tific training. Furthermore, 71% of these employees re-
ported giving recommendations about cannabis
products based on personal experience. In another
study, in which 56% of dispensary employees had
received formal training, only 47% thought that medical
decision-making was important when recommending
cannabis products. Also, most preferred a patient-
centered philosophy (77%) compared with that of a dis-
pensary staff-centered philosophy (23%).15
The majority of the limitations of this study were
related to appropriate identification of operating
dispensaries. The Colorado Marijuana Enforcement
Division has an accurate list of all state licenses that
have been issued, but this list does not necessarily
correspond to stores that are currently open. There-
fore, some dispensaries did not have a valid phone
number, which may have resulted in selection bias. In
addition, all dispensaries routing calls to a “call cen-
ter” were excluded. Despite this, it is possible that
there were “chains” of marijuana dispensaries with
similar policies but unique addresses and phone num-
bers that could have influenced our results. However,
the mystery caller design reflects “real-world” situa-
tions and allows for description of the advice pregnant
women receive when calling operating, licensed

1036 Dickson et al Cannabis Dispensary Recommendations OBSTETRICS & GYNECOLOGY

 Box 2. Representative Quotes From Cannabis Dispensary Employees in Response to Phone Script
Questions*

“I’m calling because I’m 8 weeks pregnant and nauseated. Are there any products that are recommended for morning
sickness?
 “Let me call my daughter, she just had a baby, call me back in 5 minutes.”
 “On the package it says do not consume while pregnant– ’there may be health risks associated with this product if
you are pregnant, breastfeeding, or planning on becoming pregnant.’ You are welcome to come to the shop to see if
we can find something, but I think most of the labels are going to be like that.”
 “Have you talked to your doctor? I do not want to recommend anything you know. I know what would help with
nausea, but I do not think I could legally recommend anything for someone that is pregnant, but I could recommend
something for nausea do they still let you purchase while you are pregnant?”
 “I cannot give medical advice; look it up and then call me and I’ll see if I have the product, but we do have CBD and
weed in stock.”
Why is the product recommended or not recommended?
 “All the products say it is not recommended for pregnant women use; they just do not know what it could do to the
fetus there is not enough studies out there. It is a drug, so probably not the best thing for you when you are pregnant.”
 “Technically with you being pregnant, I do not think you are supposed to be consuming that, but if I were to suggest
something, I suggest something high in THC.”
 “Legally cannot provide a recommendation.”
 “Need a doctor’s recommendation first.”
 “Edibles would not hurt the child; they would be going through your digestional [digestive] tract.”
 “They have been doing studies; as long as you are not heavily harshly smoking like the smoke I think that is the only
way it could physically damage the baby, cause you are inhaling smoke.”
Recommendations on frequency
 “In the context of edibles, start with a low dose and see how it works out for you because those types of things
would, um, not cross the blood–brain barrier so even if you have got the CBDs and the other good parts of the plants
would get in your baby’s blood system but the psychotropic properties, the THC molecule, would not get near your
baby, so basically would not be getting your baby stoned.”
 “Before your first trimester. Second trimester you do not want to overconsume. When I was pregnant and started to
feel a little nausea coming on, I did not smoke more than two times a day.”
 “I am not sure, I do not really know, I am not really too familiar with this, cause I do not want to give you the wrong
information and find out it can be harmful to your baby, so I do not want to tell you the wrong thing; just one of my
coworkers, she was pregnant and she was using flower and vaping.”
Responses regarding speaking with a health care provider
 “I think that would be a smart choice. Try for someone that is liberal or procannabis. The others are not fully
educated on the benefits of cannabis and will tell you to stay away, but always check with a medical professional.”
 “I do think you should talk to your doctor at your discretion about it. I know there are some doctors that might be really
uncomfortable with that. I do think that it is a medical professional’s responsibility to be open to talking with their patient.”
 “The doctor will probably just tell you that ’marijuana is bad for kids and will just try pushing pills on you.’ Maybe
you have a progressive doctor that will not lie to you. All the studies done back in the day were just propaganda.”
 “Google it first. Then if you feel apprehensive about it, you could ask.”
 “Most of them out here tell them not to smoke weed. Even the cancer doctors. It is so messed up. I do not know how
the baby doctors work, if they are chill or not. Just do not go stoned when you talk to them.”
 “No, because they will test you when the baby is born and can get child protective services involved; that is just the
unfortunate honest truth.”
 “In the state of Colorado you are protected, so it is not something you have to bring to their attention.they are not
gonna call CPS like they would have 10 years ago if you have MJ in your system.”
Is cannabis safe to take during pregnancy?
 “Different people opinions, kind of like alcohol; I used to be a bartender and it is legal to serve someone who is
pregnant because it is up to them so you know. I am not here to tell you you should or should not use, does that
make sense. I do know a lot of people that do use cannabis during their pregnancy though and for what they have
found, there has not been side effects that they can see,”
 “I know a lot of doctors are recommending marijuana nowadays.”
 “We have a girl that comes in and she is probably 6 months pregnant and she smokes bud but she does not smoke it as
much as she did but she still does.she said her doctor said it was ok.she said the doctor said that but I am not
a doctor.I know aspirin is ok for babies and that is pretty much what you are getting is an aspirin that is probably better.”
CBD, cannabidiol; THC, tetrahydrocannabinol; CPS, child protective services; MJ, slang for marijuana.
*The response may not be directly associated with the direct question as a result of the open-ended nature of the question.

VOL. 131, NO. 6, JUNE 2018 Dickson et al Cannabis Dispensary Recommendations 1037
dispensaries. Finally, our sample size was calculated
for our primary outcome and may have been inade-
quate for some of the secondary outcomes; therefore,
nonsignificant results should not be interpreted as
equivalent.
We recognize that recommendations from can-
nabis dispensary employees may vary depending on
who took the call at a given time and may not be
representative of all employees at the dispensary. It is
possible that some dispensaries have a policy in place
for cannabis use in pregnancy that individual employ-
ees did not follow based on personal views. Although
the phone script was piloted in dispensaries outside of
Colorado, no dispensaries outside of Colorado were
included and, thus, these findings may not be gener-
alizable to other states with legalized cannabis. Also,
the level of education and medical background of the
dispensary representative were unknown.
This study has several strengths. The random
selection of cannabis dispensaries was stratified to
ensure distribution across the state and across differ-
ent license types, and selection was from the list of all
licensed dispensaries, which strengthens generalizabil-
ity of results to all dispensaries in Colorado. Further-
more, this study was conducted in Colorado, which
was one of the first states to legalize cannabis
products. Thus, it is likely that some dispensary
respondents have prior experience with pregnant
customers requesting advice about cannabis use.
This study prompts many questions about laws
and regulations pertaining to cannabis dispensaries.
As cannabis legalization becomes more common,
women should be cautioned that advice from dispen-
sary employees might not necessarily be informed by
medical evidence. Future studies should focus on the
effects of maternal cannabis use on maternal and
neonatal outcomes in hopes of being able to provide
guidelines to care for pregnant women. Public health
initiatives should consider collaborating with dispen-
sary owners and other valuable stakeholders in
conversations about standards for advice provided
to pregnant women.
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OBSTETRICS & GYNECOLOGY